Challenge 7: Effectively Operating Public Health and Human Services Programs To Best Serve Program Beneficiaries

Why This Is a Challenge

The Department funds and operates public health and human services programs that promote health and economic and social well-being. These include, among others, programs to prevent, track, and treat acute and chronic diseases; respond to natural and man-made disasters; and protect, care for, and educate children. Many of these programs target vulnerable populations. Effective management of these programs is essential to ensure that they achieve their goals and best serve the programs' intended beneficiaries. Key challenges include (1) ensuring effective preparedness and response to current and future public health emergencies, (2) protecting the health and safety of America's vulnerable populations, and (3) ensuring access for intended beneficiaries and delivery of quality services such that beneficiaries' needs are met.

Public Health Preparedness and Emergency Response. Recent natural disasters, such as Hurricane Sandy, and disease outbreaks, such as the Ebola virus outbreak, highlight the importance of an agile public health infrastructure that can rapidly and capably respond to emergencies at home and abroad. The ability to effectively communicate and coordinate with federal, state, local, tribal, and private entities, as well as with international partners, is critical. OIG's recent review of hospitals' experiences during Hurricane Sandy revealed that the vast majority of hospitals in affected areas reported substantial challenges, including infrastructure breakdown and communication failures. The recurrence of similar problems as experienced during prior disasters highlights the need to apply knowledge gained from past experience to anticipate and prepare for new problems going forward.

The Department is also responsible for ensuring that select agents (e.g., anthrax and smallpox), which have the potential to pose a severe threat to human, animal, or plant health, are handled safely and stored securely. Earlier work by OIG identified security vulnerabilities at many Department research facilities, and recent testimony and news accounts attest to continuing problems with how these agents are inventoried and handled.

Access to and Quality of Services. To achieve program goals, the Department must ensure that qualified beneficiaries have access to high quality services. OIG work has uncovered situations in which beneficiaries could not access key services and situations in which beneficiaries received substandard services. For example, OIG found that many HRSA-funded health centers, which provide primary care for millions of patients, failed to fully adopt CDC-endorsed practices for routine HIV testing that are recommended to help combat spread of the virus. In another example, OIG found that vaccines intended for use in the Vaccines for Children (VFC) program had expired or had been improperly stored in ways that could compromise their safety or efficacy. Additional challenges arise in ensuring that children in foster care receive required health screenings.

Protecting Vulnerable Populations. OIG work has revealed potential threats to the health and safety of children served by the Child Care and Development Fund (CCDF) program of the Administration for Children and Families. CCDF provides financial assistance for child care, each month serving approximately 1.45 million children from low income families. OIG work identified vulnerabilities in states' standards for and monitoring of child care providers and suggested efforts the Department should undertake to better serve this vulnerable population.

Since first assuming responsibility for unaccompanied children in 2003, the Office of Refugee Resettlement (ORR) has cared for more than 100,000 such children, through the end of FY 2013. This year, the number of unaccompanied children arriving in the United States without lawful immigration status has dramatically increased. In 2014, the Department estimates that the total number of such unaccompanied children will reach nearly 60,000, more than double the number from the prior year. ORR faces substantial demands in adequately caring for this influx of children in an environment of heightened public and media scrutiny.

Progress in Addressing the Challenge

The Department reports that it has made progress in improving physical security and employee training related to secure storage and safe handling of select agents; however issues related to inventory control in HHS laboratories remain.

CMS is developing more comprehensive emergency preparedness requirements for Medicare providers and suppliers. The Department is currently undertaking several initiatives, including a technical assistance center, to support collaboration among federal, state, and community entities in disaster response. Similarly, in response to OIG's recommendations, the Department has established new training materials for its grantees and providers to ensure that VFC vaccines are stored according to requirements.

What Needs To Be Done

The Department must effectively deploy its resources and expertise to combat communicable diseases, such as Ebola. The Department should continue to promote federal, state, tribal, and community collaboration in major disasters and public health exigencies. While it may not be possible to predict when and where disasters will strike, the Department should prepare for a range of potential emergency scenarios and be ready to rapidly and effectively respond. Similarly, the Department must plan for, and meaningfully assist health care providers in planning for, a range of public health emergencies. Additionally, improvements in adoption and interoperability of health IT can facilitate medical care for displaced patients or patients with communicable diseases by ensuring continuity of access to health records. (For additional discussion on issues related to the secure exchange of health care information, see Management Challenge 6.)

Given the recent unprecedented surge in unaccompanied children, the Department must be prepared to meet future demand for services for additional children. OIG continues to recommend that the Department establish a memorandum of understanding with the Department of Homeland Security to clearly delineate the roles and responsibilities of each Department and facilitate gathering and exchange of information regarding unaccompanied children.

The Department should also fully implement OIG recommendations regarding CCDF to ensure compliance with state requirements related to the health and safety of children, implementation of controls for determining eligibility for receiving assistance payments, and ensuring that states implement better controls for regulating and monitoring childcare providers. OIG has also recommended strengthened health and safety requirements and use of provider background checks to reduce health and safety risks to children served by the programs.

The Department will need to take swift action to significantly improve its inventory control policies and procedures for select agents in light of recent news reports identifying significant issues with inventory controls, which the Department has confirmed.